Medicare supports end-of-life planning

Arlene Krejci volunteers Wednesday at the Lowcountry Senior Center on James Island. She already has discussed with her children and her doctor how she wishes to spend her last days.

Seventy-three-year-old Arlene Krejci said talking to her adult children about how she wants to die reminded her of the conservation she had with them years ago about the birds and the bees.

“It was the same thing as talking to your children about sex. ... You don’t wait until your child is 15 to have the conversation. You have the conversation as they’re coming up. It’s easier,” said Krejci, who lives on James Island and volunteers at the Lowcountry Senior Center. “We had the conversation (about death) while I’m fine and healthy. Don’t wait until I’m sucking on the oxygen tank or whatever because then it’s a shock.”

Krejci contends that this end-of-life discussion was necessary, but not very difficult. She’s in the minority.

Various reports indicate only a quarter to a third of adults in this country have laid out their wishes in an “advanced care directive,” a document that details, among other things, the health care interventions that they want in their final days.

Six years ago, lawmakers tried to prioritize this type of end-of-life planning in the federal Affordable Care Act, but the debate quickly devolved into mudslinging as tea party politicians accused the law’s proponents of sanctioning government-run “death panels.”

“The medical community was very frustrated at that time because this is a good thing, but it got demonized and politicized, and when that happened, you can’t do anything about it,” said Dr. Pat Cawley, Medical University Hospital’s executive director. “You have to retreat.”

Now, Cawley, and others, are hopeful that the country is ready to move past this inflammatory rhetoric. Medicare announced earlier this month that it will start paying doctors to provide “advanced care planning” for beneficiaries on Jan. 1.

The appointments — during which physicians will basically discuss with their patients how they’d like to spend their dying days — will be voluntary for some 55 million Americans who qualify for Medicare. The federal government technically already pays doctors to provide this service, but only during a patient’s “Welcome to Medicare” visit.

“They may not need these services when they first enroll,” the federal Centers for Medicare & Medicaid acknowledged in a press release about the new policy. The upcoming change will allow patients and their doctors to discuss advanced-care planning when it’s most convenient for both of them.

“It’s hugely ground-breaking,” said Dr. Scott Lake, director of palliative medicine and post-acute care for Roper St. Francis. “We have traditionally paid for inventions like MRIs and chemotherapy and all these other kinds of things, and now we’re saying having conversations about what the patients’ wishes and goals are is equally as important as some of the other interventions we might do.”

These conversations will likely cover the types of treatments patients want to forgo at the end; how long, if at all, patients want to survive on life-support; and whether they’d like to die at a hospital, at a hospice center or at home.

Betty Ochoa, 82, who lives in West Ashley, said she has seen friends die in all three settings.

“Most of them, though, have done it in hospice, which seems to me, in today’s time, the ideal way — not to be hooked up to 10,000 medications and tubes and have that hospital bill just climb up exorbitantly,” Ochoa said. “That’s one thing I definitely don’t want to have.”

Ochoa wrote down her end-of-life decisions in a document that she shared with her daughter and her family doctor.

“I’m very realistic,” she said. “And having seen what had happened to different people, and living in Charleston alone, I made up my mind to make sure everyone who needed to be informed was duly informed.”

While her doctor was “delighted” to have this conversation, Ochoa recalled, other physicians may be more reluctant. Some medical professionals aren’t always comfortable talking about death with healthy patients — nor are all of them trained very well to do it.

A report published earlier this year by the Institute of Medicine, called “Dying in America,” explains that few medical educators teach the communication skills needed for physicians to provide “good end-of-life care.”

“The conversation, first of all, is a very, very hard conversation. ... Not every doctor at MUSC is good at that conversation,” Cawley said. “Some people are naturally gifted at it, but I would say the vast majority of people who do it — and do it well — have gotten training.”

Lake said this may be one of the drawbacks to the new Medicare reimbursement policy. Just because the federal government is prepared to pay physicians to facilitate more of these end-of-life health care conversations with their Medicare patients, physicians may need time to catch up.

“These conversations take time and the resulting document — or whatever you come out with — is only as good as the quality of the conversation that you have had,” Lake said. “I don’t know that all physicians are ready to have an experienced conservation with the patient and their family members.”

The Centers for Medicare & Medicaid have proposed reimbursing doctors $86 for the first 30 minutes of an “advanced care planning” consultation with a Medicare patient, and $75 for every 30-minute block after that, Lake said.

The new policy is open for public comment at cms.gov.

Reach Lauren Sausser at 937-5598.